Answer to Question 1
A
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A The nurse applies a small amount of soap and washes hands, using plenty of lather and friction, for at least 10 to 15 seconds.
B The correct length of time for this step of hand hygiene is not 20 to 30 seconds.
C The correct length of time for this step of hand hygiene is not 30 to 45 seconds.
D The correct length of time for this step of hand hygiene is not 45 to 60 seconds.
Answer to Question 2
C
Patients with tracheotomies rely on the tracheostomy to provide a stable open airway. The nurse is most concerned about a dementia patient who is extubating himself unknowingly. The nurse is also concerned that the patient would not be able to cough up his own secretions and could occlude the tracheostomy, putting him at risk for Ineffective airway clearance. Nursing priorities are airway, breathing, and circulation. Frequently occurring nursing diagnoses should be addressed before Risk diagnoses. Skin breakdown and infection are not immediately life threatening.